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Overview

CXL has transformed the way we think about keratoconus management. As the procedure can stop the progression of keratoconus, early detection and CXL will most likely be a major consideration in the development of clinical pathways for keratoconus.

However, at this point in time, the majority of patients considering CXL are already wearing contact lenses of one sort or another. It is important to consider planning how that contact lens wear is going to be managed before the patient embarks on the CXL procedure itself.

RGP wear and CXL

If a patient with normal corneas was to choose to have refractive surgery, there would be a recommendation to leave RGP lenses out for a period of time before surgery.

This is due to the fact that rigid lenses mould the cornea (indeed, the process of Ortho K depends on this happening) and the cornea needs time to return to its normal state before surgery, so that proper assessments can be made.

This process can take around 6 weeks for normals (1) and may take considerably longer for a softer, keratoconic cornea.

Additionally, as a post CXL cornea tends to fluctuate in shape significantly, it is generally advised not to return to RGP for around 2 months post op.

This situation can cause real problems for patients who are reliant on contact lens wear for work, driving etc.

The benefit of soft lenses

Soft lenses can induce some moulding but nowhere near as much as RGP lens wear (2).

Patients can generally wear their soft lenses up to the day before CXL surgery and, since they flex with corneal shape changes, contact lens wear can be resumed around 5-10 days post surgery.

Thus, it can be beneficial to the patient to be refitted into soft lenses before surgery, so that the operation itself causes the least disruption to the patients life.

Corneal rehabilitation

Many long term rigid lens wearers develop corneal haze and localised oedematous scarring. Much of this is due to the poor healing qualities of a keratoconic cornea.

Haze and scarring are contra-indications for CXL, so it is useful to understand that some of these issues can be resolved by refitting into soft lenses. If a cornea can be rehabilitated in this way, then the possibility of successful CXL is much higher.